Clinical Associate Professor West Virginia University School of Pharmacy Charleston, West Virginia
Introduction: We report an unusual case of death from pulmonary embolism not associated with a central venous line (CVL) or other thrombotic risks during resuscitation of diabetic ketoacidosis (DKA).
Description: The patient was a 16-year-old girl who presented complaining of hyperglycemia and was found to be in moderate DKA. Her medical history was unremarkable save for diabetes mellitus type I, and she had no specific risk factors for thromboembolic disorder, including family history, prothrombotic medications, inactivity, or body habitus. Following treatment with continuous insulin therapy and IV fluids, she was transitioned to her home intermittent insulin regimen. At 27 hours into the hospital stay, she became unconscious, then rapidly became pulseless. Immediately prior to this event the patient had been alert, ambulating, denied discomfort, with laboratory values within reference ranges. A glucose measurement made at the time of the collapse was 112 mg/dL. Cardiopulmonary resuscitation was initiated. Besides standard Pediatric Advanced Life Support measures, mannitol and hypertonic saline were administered. The patient died following one hour and thirteen minutes of resuscitation effort. Postmortem examination revealed the presence of a large pulmonary embolus obstructing both pulmonary artery branches.
Discussion: Although there are extensive reports of thrombotic events in patients treated for DKA, they mostly report cerebral injury or events associated with CVLs. There are, however, case reports of DKA patients suffering pulmonary embolism, usually associated with preexisting prothrombotic conditions. Our patient was unique in that she had no appreciable thrombotic risk, moderate DKA and physiologic serum osmolality, suggesting that her thrombosis risk was low.
Current guidelines recommend prophylactic anticoagulation in DKA only in the context of a CVL. Current pediatric critical care practice generally only employs prophylactic anticoagulation in adolescent patients with elevated thrombotic risk. Given the relatively low risk of adverse events with chemoprophylactic anticoagulation, and the profound consequences of a serious thrombosis, perhaps a reassessment of the role of anticoagulation in DKA is warranted.
